Analysis of factors influencing surgical intervention after percutaneous catheter drainage in patients with infected necrotizing pancreatitis and development of a predictive model_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

GAO Zhongti , CHE Shengfu , QING Huiguo , LI Long , JIAO Zuoyi ,  YU Zeyuan

Department of General Surgery, Lanzhou University Second Hospital, Lanzhou 730030, P. R. China;

Corresponding?author：

YU Zeyuan, Email: yuzy17@lzu.edu.cn

Keywords：

infected necrotizing pancreatitis; percutaneous catheter drainage; surgical intervention; risk factor; nomogram

DOI：

10.7507/1007-9424.202505010

Video：

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Objective To investigate the factors influencing the need for surgical intervention after percutaneous catheter drainage (PCD) in patients with infected necrotizing pancreatitis (INP), and to construct and validate a nomogram-based predictive model. Methods A total of 197 INP patients who underwent PCD at the Second Hospital of Lanzhou University between January 2021 and December 2023 were retrospectively enrolled. Patients were randomly divided into a training cohort (n=137) and a validation cohort (n=60) in a 7∶3 ratio. Univariate and multivariate logistic regression analyses were performed in the training cohort, and a nomogram was developed based on the multivariate results. Model discrimination was evaluated using receiver operating characteristic (ROC) curves, calibration was assessed using calibration plots, and clinical utility was examined using decision curve analysis (DCA) in both cohorts. Results Multivariate logistic regression revealed that C-reactive protein (CRP) [OR=1.028, 95%CI (1.005, 1.051), P=0.015], neutrophil-to-lymphocyte ratio (NLR) [OR=1.876, 95%CI (1.240, 2.839), P=0.003], computed tomography severity index (CTSI) [OR=6.701, 95%CI (2.827, 15.884), P<0.001], and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score [OR=1.353, 95%CI (1.075, 1.703), P=0.010]were independent predictors of surgical intervention after unsuccessful PCD. A nomogram was constructed accordingly. The areas under the ROC curve (AUCs) of the predictive model were 0.95 [95%CI (0.92, 0.98)]in the training cohort and 0.94 [95%CI (0.88, 0.99)]in the validation cohort. Calibration curves and Hosmer-Lemeshow goodness-of-fit tests demonstrated good agreement between predicted and observed outcomes (training cohort P=0.633, validation cohort P=0.236). DCA showed that the nomogram provided the greatest net clinical benefit within threshold probabilities of 5%–97% in the training cohort and 10%–95% in the validation cohort. Conclusions The predictive model which including CRP, NLR, CTSI score and APACHE II score has significant predictive value of surgical intervention following PCD failure in INP patients. The proposed nomogram offers a reliable tool for early identification and clinical decision-making in this population.

1.	Szatmary P, Grammatikopoulos T, Cai W, et al. Acute pancreatitis: diagnosis and treatment. Drugs, 2022, 82(12): 1251-1276.
2.	Boxhoorn L, Voermans RP, Bouwense SA, et al. Acute pancreatitis. Lancet, 2020, 396(10252): 726-734.
3.	Crockett SD, Wani S, Gardner TB, et al. American Gastroenterological Association institute guideline on initial management of acute pancreatitis. Gastroenterology, 2018, 154(4): 1096-1101.
4.	Mederos MA, Reber HA, Girgis MD. Acute pancreatitis: a review. JAMA, 2021, 325(4): 382-390.
5.	Maurer LR, Fagenholz PJ. Contemporary surgical management of pancreatic necrosis. JAMA Surg, 2023, 158(1): 81-88.
6.	Wroński M, Cebulski W, Karkocha D, et al. Ultrasound-guided percutaneous drainage of infected pancreatic necrosis. Surg Endosc, 2013, 27(11): 4397-4398.
7.	van Baal MC, van Santvoort HC, Bollen TL, et al. Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br J Surg, 2011, 98(1): 18-27.
8.	Luckhurst CM, El Hechi M, Elsharkawy AE, et al. Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step-Up Approach: Comparison with a Modern Open Necrosectomy Cohort. J Am Coll Surg, 2020, 230(6): 873-883.
9.	Onnekink AM, Boxhoorn L, Timmerhuis HC, et al. Endoscopic versus surgical step-up approach for infected necrotizing pancreatitis (ExTENSION): long-term follow-up of a randomized trial. Gastroenterology, 2022, 163(3): 712-722.
10.	Maatman TK, Flick KF, Roch AM, et al. Operative pancreatic debridement: contemporary outcomes in changing times. Pancreatology. 2020, 20(5): 968-975.
11.	Gupta R, Kulkarni AA, Babu R, et al. Predrainage and postdrainage prognostic nomograms to predict outcome of percutaneous drainage for infected pancreatic and peripancreatic necrotic collections. Pancreas, 2019, 48(9): 1212-1219.
12.	Greenberg JA, Hsu J, Bawazeer M, et al. Clinical practice guideline: management of acute pancreatitis. Can J Surg, 2016, 59(2): 128-140.
13.	Maatman TK, McGuire SP, Flick KF, et al. Outcomes in endoscopic and operative transgastric pancreatic debridement. Ann Surg, 2021, 274(3): 516-523.
14.	Arvanitakis M, Dumonceau JM, Albert J, et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy, 2018, 50(5): 524-546.
15.	中華醫學會外科學分會胰腺外科學組. 中國急性胰腺炎診治指南 (2021). 浙江實用醫學, 2021, 26(6): 511-519,535.
16.	Garret C, Douillard M, David A, et al. Infected pancreatic necrosis complicating severe acute pancreatitis in critically ill patients: predicting catheter drainage failure and need for necrosectomy. Ann Intensive Care, 2022, 12(1): 71. doi: 10.1186/s13613-022-01039-z.
17.	陳敏, 武鵬宇, 鄧杲, 等. 基于免疫應答的急性胰腺炎中西醫協同診治策略. 中國普外基礎與臨床雜志, 2024, 31(2): 155-160.
18.	Besselink MG, van Santvoort HC, Nieuwenhuijs VB, et al. Minimally invasive ‘step-up approach’ versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial [ISRCTN13975868]. BMC surgery, 2006, 6: 6. doi: 10.1186/1471-2482-6-6.
19.	文君, 單晶, 武鵬宇, 蔣崔楠, 等. 外科干預聯合超聲內鏡下穿刺引流治療感染性胰腺壞死的臨床效果評價: 單中心回顧性歷史對照研究. 中國普外基礎與臨床雜志, 2024, 31(2): 175-181.
20.	van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med, 2010, 362(16): 1491-1502.
21.	Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology, 2013, 13(4 Suppl 2): e1-15. doi: 10.1016/j.pan.2013.07.063.
22.	Lu F, Zhang Y, Yu J, et al. Clinical value of BISAP score combined with CRP and NLR in evaluating the severity of acute pancreatitis. Medicine, 2023, 102(45): e35934. doi: 10.1097/MD.0000000000035934.
23.	Stirling AD, Moran NR, Kelly ME, et al. The predictive value of C-reactive protein (CRP) in acute pancreatitis - is interval change in CRP an additional indicator of severity? HPB (Oxford), 2017, 19(10): 874-880.
24.	Azab B, Jaglall N, Atallah JP, et al. Neutrophil-lymphocyte ratio as a predictor of adverse outcomes of acute pancreatitis. Pancreatology, 2011, 11(4): 445-452.
25.	Ahsen A, Ulu MS, Yuksel S, et al. As a new inflammatory marker for familial Mediterranean fever: neutrophil-to-lymphocyte ratio. Inflammation, 2013, 36(6): 1357-1362.
26.	Xinyu X, Jiang Z, Qing A, et al. Clinical significance of PCT, CRP, IL-6, NLR, and TyG Index in early diagnosis and severity assessment of acute pancreatitis: a retrospective analysis. Sci Rep, 2025, 15(1): 2924. doi: 10.1038/s41598-025-86664-x.
27.	Yang ZW, Weng CZ, Wang J, et al. The role of Card9 overexpression in peripheral blood mononuclear cells from patients with aseptic acute pancreatitis. J Cell Mol Med. 2016, 20(3): 441-449.
28.	Pinhu L, Qin Y, Xiong B, et al. Overexpression of Fas and FasL is associated with infectious complications and severity of experimental severe acute pancreatitis by promoting apoptosis of lymphocytes. Inflammation, 2014, 37(4): 1202-1212.
29.	Balthazar EJ, Robinson DL, Megibow AJ, et al. Acute pancreatitis: value of CT in establishing prognosis. Radiology, 1990, 174(2): 331-336.
30.	Hollemans RA, Bollen TL, van Brunschot S, et al. Predicting success of catheter drainage in infected necrotizing pancreatitis. Ann Surg, 2016, 263(4): 787-792.
31.	Li G, Li S, Cao L, et al. Nomogram development and validation for predicting minimally invasive step-up approach failure in infected necrotizing pancreatitis patients: a retrospective cohort study. Int J Surg, 2023, 109(6): 1677-1687.
32.	Babu RY, Gupta R, Kang M, et al. Predictors of surgery in patients with severe acute pancreatitis managed by the step-up approach. Ann Surg, 2013, 257(4): 737-750.
33.	楊帆, 孔德華, 王見斌, 等. 動脈血乳酸、乳酸清除率與重癥肺炎機械通氣患者APACHE Ⅱ評分及預后的相關性. 河北醫藥, 2021, 43(05): 740-743.

1. Szatmary P, Grammatikopoulos T, Cai W, et al. Acute pancreatitis: diagnosis and treatment. Drugs, 2022, 82(12): 1251-1276.
2. Boxhoorn L, Voermans RP, Bouwense SA, et al. Acute pancreatitis. Lancet, 2020, 396(10252): 726-734.
3. Crockett SD, Wani S, Gardner TB, et al. American Gastroenterological Association institute guideline on initial management of acute pancreatitis. Gastroenterology, 2018, 154(4): 1096-1101.
4. Mederos MA, Reber HA, Girgis MD. Acute pancreatitis: a review. JAMA, 2021, 325(4): 382-390.
5. Maurer LR, Fagenholz PJ. Contemporary surgical management of pancreatic necrosis. JAMA Surg, 2023, 158(1): 81-88.
6. Wroński M, Cebulski W, Karkocha D, et al. Ultrasound-guided percutaneous drainage of infected pancreatic necrosis. Surg Endosc, 2013, 27(11): 4397-4398.
7. van Baal MC, van Santvoort HC, Bollen TL, et al. Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br J Surg, 2011, 98(1): 18-27.
8. Luckhurst CM, El Hechi M, Elsharkawy AE, et al. Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step-Up Approach: Comparison with a Modern Open Necrosectomy Cohort. J Am Coll Surg, 2020, 230(6): 873-883.
9. Onnekink AM, Boxhoorn L, Timmerhuis HC, et al. Endoscopic versus surgical step-up approach for infected necrotizing pancreatitis (ExTENSION): long-term follow-up of a randomized trial. Gastroenterology, 2022, 163(3): 712-722.
10. Maatman TK, Flick KF, Roch AM, et al. Operative pancreatic debridement: contemporary outcomes in changing times. Pancreatology. 2020, 20(5): 968-975.
11. Gupta R, Kulkarni AA, Babu R, et al. Predrainage and postdrainage prognostic nomograms to predict outcome of percutaneous drainage for infected pancreatic and peripancreatic necrotic collections. Pancreas, 2019, 48(9): 1212-1219.
12. Greenberg JA, Hsu J, Bawazeer M, et al. Clinical practice guideline: management of acute pancreatitis. Can J Surg, 2016, 59(2): 128-140.
13. Maatman TK, McGuire SP, Flick KF, et al. Outcomes in endoscopic and operative transgastric pancreatic debridement. Ann Surg, 2021, 274(3): 516-523.
14. Arvanitakis M, Dumonceau JM, Albert J, et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy, 2018, 50(5): 524-546.
15. 中華醫學會外科學分會胰腺外科學組. 中國急性胰腺炎診治指南 (2021). 浙江實用醫學, 2021, 26(6): 511-519,535.
16. Garret C, Douillard M, David A, et al. Infected pancreatic necrosis complicating severe acute pancreatitis in critically ill patients: predicting catheter drainage failure and need for necrosectomy. Ann Intensive Care, 2022, 12(1): 71. doi: 10.1186/s13613-022-01039-z.
17. 陳敏, 武鵬宇, 鄧杲, 等. 基于免疫應答的急性胰腺炎中西醫協同診治策略. 中國普外基礎與臨床雜志, 2024, 31(2): 155-160.
18. Besselink MG, van Santvoort HC, Nieuwenhuijs VB, et al. Minimally invasive ‘step-up approach’ versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial [ISRCTN13975868]. BMC surgery, 2006, 6: 6. doi: 10.1186/1471-2482-6-6.
19. 文君, 單晶, 武鵬宇, 蔣崔楠, 等. 外科干預聯合超聲內鏡下穿刺引流治療感染性胰腺壞死的臨床效果評價: 單中心回顧性歷史對照研究. 中國普外基礎與臨床雜志, 2024, 31(2): 175-181.
20. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med, 2010, 362(16): 1491-1502.
21. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology, 2013, 13(4 Suppl 2): e1-15. doi: 10.1016/j.pan.2013.07.063.
22. Lu F, Zhang Y, Yu J, et al. Clinical value of BISAP score combined with CRP and NLR in evaluating the severity of acute pancreatitis. Medicine, 2023, 102(45): e35934. doi: 10.1097/MD.0000000000035934.
23. Stirling AD, Moran NR, Kelly ME, et al. The predictive value of C-reactive protein (CRP) in acute pancreatitis - is interval change in CRP an additional indicator of severity? HPB (Oxford), 2017, 19(10): 874-880.
24. Azab B, Jaglall N, Atallah JP, et al. Neutrophil-lymphocyte ratio as a predictor of adverse outcomes of acute pancreatitis. Pancreatology, 2011, 11(4): 445-452.
25. Ahsen A, Ulu MS, Yuksel S, et al. As a new inflammatory marker for familial Mediterranean fever: neutrophil-to-lymphocyte ratio. Inflammation, 2013, 36(6): 1357-1362.
26. Xinyu X, Jiang Z, Qing A, et al. Clinical significance of PCT, CRP, IL-6, NLR, and TyG Index in early diagnosis and severity assessment of acute pancreatitis: a retrospective analysis. Sci Rep, 2025, 15(1): 2924. doi: 10.1038/s41598-025-86664-x.
27. Yang ZW, Weng CZ, Wang J, et al. The role of Card9 overexpression in peripheral blood mononuclear cells from patients with aseptic acute pancreatitis. J Cell Mol Med. 2016, 20(3): 441-449.
28. Pinhu L, Qin Y, Xiong B, et al. Overexpression of Fas and FasL is associated with infectious complications and severity of experimental severe acute pancreatitis by promoting apoptosis of lymphocytes. Inflammation, 2014, 37(4): 1202-1212.
29. Balthazar EJ, Robinson DL, Megibow AJ, et al. Acute pancreatitis: value of CT in establishing prognosis. Radiology, 1990, 174(2): 331-336.
30. Hollemans RA, Bollen TL, van Brunschot S, et al. Predicting success of catheter drainage in infected necrotizing pancreatitis. Ann Surg, 2016, 263(4): 787-792.
31. Li G, Li S, Cao L, et al. Nomogram development and validation for predicting minimally invasive step-up approach failure in infected necrotizing pancreatitis patients: a retrospective cohort study. Int J Surg, 2023, 109(6): 1677-1687.
32. Babu RY, Gupta R, Kang M, et al. Predictors of surgery in patients with severe acute pancreatitis managed by the step-up approach. Ann Surg, 2013, 257(4): 737-750.
33. 楊帆, 孔德華, 王見斌, 等. 動脈血乳酸、乳酸清除率與重癥肺炎機械通氣患者APACHE Ⅱ評分及預后的相關性. 河北醫藥, 2021, 43(05): 740-743.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Latest ArticlesAnalysis of factors influencing surgical intervention after percutaneous catheter drainage in patients with infected necrotizing pancreatitis and development of a predictive model

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